3-81
Prostatitis is commonly due to an infection, so an empiric trial of antibiotics is useful. Urinalysis is suggestive
but not conclusive.
Subjective: Symptoms
Difficulty urinating: Obstructive symptoms include slow start, low flow and dribbling; irritative symptoms
include frequency (> q 2 hours) and/or urgency; pain in the head of the penis or under the scrotum; low
back pain; fever.
Objective: Signs
Using Basic Tools: Tender prostate with/without tender pelvic floor or coccyx (palpate 360° on rectal exam);
distended bladder
Using Advanced Tools: Lab: Urinalysis: heme and leukoesterase positive urine (infection).
Assessment:
Differential Diagnosis
Irritative voiding symptoms with or without fever - urinary tract infection until proven otherwise, distal ureteral
stone, urethral stricture, bladder neck dysfunction, bladder or prostate cancer, foreign body in bladder, overflow
incontinence.
Obstructive voiding - enlarged prostate, urethral stricture, and neurologic disease of the spine or peripheral
nerves.
Painful prostate - urinary tract infection, bladder neck dysfunction/prostatodynia/pelvic floor dysfunction,
musculoskeletal pain, coccydynia, seminal vesiculitis
Plan:
Treatment: Infection
Primary:
- If the patient is lethargic and febrile, begin high dose IV ampicillin 1-2 gm IV q 6-8h and gentamicin 5
mg/ kg IV qd. If penicillin allergic, use IV fluoroquinolones (Levaquin 250 mg IV q day or Cipro 400
mg IV bid) or vancomycin 1 gm IV bid and gentamicin 5 mg per kg IV qd. Hydrate aggressively. When
the patient is afebrile, switch to oral fluoroquinolone (see UTI section) for a total of 30 days. - If the patient is alert and manifesting either low-grade fever or no fever, treat with fluoroquinolones (see
UTI section). - Treat any male suspected of having an infection for 30 days regardless of the location of symptoms
(kidney, prostate or scrotum). Infected urine can easily reflux into prostatic ducts, therefore assume the
prostate is infected. - If symptoms persist and urinalysis continues to be abnormal without improvement after 3-5 days, suspect
bacterial resistance and change antibiotics. - If a bladder is palpated, attempt to pass a Foley catheter (Procedure: Bladder Catherization). Inability
to pass catheter suggests a stricture. If patient’s symptoms worsen, consider suprapubic aspiration (see
Procedure: Suprapublic Bladder Aspiration). - If the entire pelvic floor is tender, pain is not from prostate alone. Treat for musculoskeletal pain with
NSAIDs.
Alternative Antibiotics:
Septra DS po tid until fever resolves, followed by Septra DS po bid x 30 days, Augmentin 500 mg po bid x
30 days, or Keflex 500 mg po qid x 30 days. Doxycycline or Vibramycin are not as effective since they are
bacterio-static, and should only be used (100 mg po bid) if there is no other alternative. Nitrofurantoin has
minimal tissue penetration and should not be used in prostatitis.
Primitive: If patients are unable to void, have them sit in a tub of warm water and ask them to void in the tub.
The warm water can relax the perineum, decrease pain and encourage voiding.
Treatment: No Infection